Meeting the UN Sustainable Development Goals for mental health: why greater prioritization and adequately tracking progress are critical
Authors: Jody Heymann, Aleta Sprague
Journal: World Psychiatry (2023)

The United Nations (UN) Sustainable Development Goal (SDG) 3, adopted by all the world's nations in 2015, is to "ensure healthy lives and promote well-being for all at all ages". For the first time, the global goals explicitly included mental health: in target 3.4, countries agreed to "promote mental health and well-being" through prevention and treatment to reduce premature mortality by one-third, and in target 3.5 countries committed to "strengthen the prevention and treatment of substance abuse". Yet, halfway to the 2030 deadline for achieving the SDGs, the available evidence suggests that we are not on track to meet even these important but modest goals. Despite taking the first step of creating mental health targets, the UN has only been measuring one mental health outcome indicator, the suicide mortality rate, and official monitoring statistics show that global suicide rates decreased just by 3% from 2015 to 2019 (the most recent year for which data are available)1 – far too slowly to meet the one-third reduction target. Accelerating reduction in suicides requires that we support and monitor advances in access to preventive care. Currently, however, the global community is not only failing to meet the SDG suicide reduction target, but also failing to measure whether people can access the services that could make a difference. The SDG target 3.8 envisions the achievement of universal health coverage, while additional targets focus on the development of the health workforce and access to essential medicines. Yet the UN's measurement of these targets overlooks questions critical to improving mental health outcomes: do countries' health systems cover not only physical but also mental health services, including treatment for depression? How robust is the mental health workforce? How widely available are essential medicines for depression and other mental health conditions? SDG indicator 3.b.3 measures the share of health facilities with "a core set of relevant essential medicines", but does not specifically account for mental health therapeutics. Similarly, the indicator on "health worker density and distribution" includes data on physicians, nurses, and pharmaceutical and laboratory staff, but not mental health care providers specifically. This neglect is striking, given that the World Health Organization (WHO) ranks depression as the "single largest contributor to global disability"1, and research has shown that mental health conditions are responsible for 13% of disability-adjusted life years2. The inadequate attention to mental health is even more concerning in the context of prior studies documenting disparities between mental and physical health services. Globally, median government expenditure on mental health services comprises just 2.1% of health spending overall3. Past WHO estimates found that just 13 mental health workers are available per 100,000 population3, compared to approximately 620 total health workers4, making clear that developing the mental health workforce requires greater attention. Moreover, the most recent WHO Mental Health Atlas, which reports on a subset of countries every three years, indicated that only around half of member states covered mental health in their national insurance programs3. Yet, the UN has bypassed the opportunity to measure global progress in these areas regularly as part of SDG monitoring, despite demonstrating the feasibility of doing so for other urgent health issues. Indeed, the global community already tracks other areas effectively, accelerating progress. Past global efforts to improve monitoring of maternal health coverage yielded the consistent collection of national-level data about number of prenatal visits, use of modern contraceptives, and presence of a skilled birth attendant, and, while much work remains, global maternal mortality rates fell 38% from 2000 to 20175. Likewise, past efforts to measure global vaccine access have collected detailed annual data from all countries on immunization financing, coverage and policies, supporting substantial increases in uptake of life-saving vaccines globally. If all countries devoted similar attention to mental health services – quality, access and affordability – we could achieve the suicide and substance abuse targets of the SDGs, while simultaneously improving prevention and treatment of a wide array of mental health conditions. To be sure, access to mental health care and medication are not the only factors that influence suicide risk; social and environmental factors – including job loss, discriminatory norms, isolation, and access to lethal means – are important contributors to suicide attempts and deaths6. Nevertheless, adequate mental health services and pharmacological treatments are essential to addressing the biological, psychological and clinical factors that independently affect suicide risk. Moreover, the SDGs provide a framework not only for improving prevention and treatment of mental health conditions, but also for improving the quality of life of people living with mental health conditions. As recognized by the UN Convention on the Rights of Persons with Disabilities, both mental and physical health conditions often are not innately disabling, but have the potential to limit full participation depending on the social environment and degree of discrimination versus inclusion. Countries agreed through SDG 4 to "ensure inclusive and equitable quality education" and reduce disparities across disability status and other measures. Both the goals for decent work (SDG 8) and inequality (SDG 10) also recognize the full equality of people living with disabilities, and countries' responsibility to uphold equal rights and full inclusion. Target 8.5 explicitly calls for "achiev[ing] full and productive employment and decent work for… persons with disabilities". Similarly, indicator 10.3.1 measures the share of the population that has faced discrimination based on disability status in the past year. Currently, however, with respect to both work and education, youth and adults with mental health conditions or intellectual disabilities face among the highest rates of stigma and exclusion7. Yet, the SDG monitoring process has collected little data on access to quality education for children with disabilities overall, and even less on the experience of children with mental health conditions. Meanwhile, data available from other sources suggest that we have far to go: our study of policies in 193 countries found that over one-third fail to even guarantee integrated education along with individualized supports for children with disabilities, and much less specifically address the needs of children with mental health conditions8. Regarding employment, the SDG indicators require tracking average wages and unemployment rates for workers with disabilities, but data are currently only available for the latter; similarly, though indicator 10.2.1 calls for data on income inequality by disability, measures are currently unavailable. Moreover, there are no specific efforts to monitor improvements in inclusive employment for people with mental health conditions. Again, these gaps are concerning, given other research indicating that many countries fall short: our center's data show that, as of 2021, only 46% of countries worldwide explicitly guaranteed reasonable accommodations for workers with mental and/or intellectual disabilities9. It is not too late for the SDGs to provide an opportunity for accelerating progress in preventing poor mental health, treating mental health conditions, and improving the quality of life of people living with mental health conditions. To do that, however, we need to measure annually not only the suicide mortality rate, but also comprehensive coverage of mental health services in national health systems; the density of the mental health care workforce; the accessibility of essential mental health therapeutics; and the extent to which countries are ensuring the full inclusion of people with mental health conditions in education and employment. Only by specifically prioritizing and tracking progress for mental health prevention, treatment and equal rights can we create a world where meeting mental health needs is not an afterthought, where explicit and implicit discrimination is eliminated, and where all people can lead full and healthy lives.